Prone ventilation in trauma or surgical patients with acute lung injury and adult respiratory distress syndrome: is it beneficial?

BACKGROUND: To compare the effectiveness of supine versus prone kinetic therapy in mechanically ventilated trauma and surgical patients with acute lung injury (ALI) and adult respiratory distress syndrome (ARDS). METHODS: A retrospective review of all patients with ALI/ARDS who were placed on either a supine (roto-rest) or prone (roto-prone) oscillating bed was performed. Data obtained included age, revised trauma score (RTS), base deficit, Injury Severity Score (ISS), head Abbreviated Injury Scale score (AIS), chest (AIS), PaO2/FiO2 ratio, FiO2 requirement, central venous pressure (CVP), days on the bed, ventilator days, use of pressors, complications, mortality, and pulmonary-associated mortality. Data are expressed as mean+/-SE with significance attributed to p<0.05. RESULTS: From March 1, 2004 through May 31, 2006, 4,507 trauma patients were admitted and 221 were identified in the trauma registry as having ALI or ARDS. Of these, 53 met inclusion criteria. Additionally, 8 general surgery patients met inclusion criteria. Of these 61 patients, 44 patients were positioned supine, 13 were placed prone, and 4 patients that were initially placed supine were changed to prone positioning. There was no difference between the groups in age, CVP, ISS, RTS, base deficit, head AIS score, chest AIS score, abdominal AIS score, or probability of survival. The PaO2/FiO2 ratios were not different at study entry (149 vs. 153, p=NS), and both groups showed improvement in PaO2/FiO2 ratios. However, the prone group had better PaO2/FiO2 ratios than the supine group by day 5 (243 vs. 200, p=0.066). The prone group had fewer days on the ventilator (13.6 vs. 24.2, p=0.12), and shorter hospital lengths of stay (22 days vs. 40 days, p=0.08). There were four patients who failed to improve with supine kinetic therapy that were changed to prone kinetic therapy. These patients had significant improvements in PaO2/FiO2 ratio, and significantly lower FiO2 requirements. There were 18 deaths (7 pulmonary related) in the supine group and 1 death in the prone group (p < 0.01 by chi test). CONCLUSIONS: ALI/ARDS patients who received prone kinetic therapy had greater improvement in PaO2/FiO2 ratio, lower mortality, and less pulmonary-related mortality than did supine positioned patients. The use of a prone-oscillating bed appears advantageous for trauma and surgical patients with ALI/ARDS and a prospective, randomized trial is warranted.

Aggressive traffic enforcement: a simple and effective injury prevention program.

PURPOSE: To investigate whether an aggressive traffic violation enforcement program could reduce motor vehicle crashes (MVCs), injury collisions, fatalities, and fatalities related to speed, and decrease injury severity in crash victims treated at the trauma center. METHODS: A vigorous enforcement program was established within Fresno, Calif, city boundaries using increased traffic patrol officers. Data on citations, collisions, fatal collisions, and fatalities related to speed, as well as injury severity from the trauma registry, were collected for the year before program onset (2002), during the first year (2003), and after full implementation (2004). U.S. Census Bureau information was used for population. Statistical analysis was performed using Fisher's exact test and independent samples t test with significance attributed to p < 0.05. RESULTS: There were significant increases in citations issued, with marked decreases in motor vehicle crashes, injury collisions, fatalities, and fatalities related to speed. There was a decrease in admissions from MVCs, a significant decrease in the number of patients with moderate injury severity (Injury Severity Score of 10-16; p < 0.01), a decrease in hospital length of stay for all MVC victims, and a decrease in hospital charges for MVC patients. These changes were not seen in the area of Fresno County outside the area of increased enforcement. CONCLUSIONS: Aggressive traffic enforcement decreased MVCs, crash fatalities, and fatalities related to speed, and it decreased injury severity. This is a simple, easily implemented injury prevention program with immediate benefit.

Occult traumatic hemothorax: when can sleeping dogs lie?

BACKGROUND: Size of traumatic occult hemothorax on admission requiring drainage has not been defined. Computed axial tomography (CAT) may guide drainage criteria. METHODS: A retrospective review of patients with hemothoraces on CAT was performed. Extrapolating previously described methods of pleural fluid measurement, hemothoraces were quantified using the fluid stripe in the dependent pleural "gutter." Data included patient age, injury severity, and intervention (thoracentesis or tube thoracostomy). RESULTS: Seventy-eight patients with 99 occult hemothoraces met the criteria for study inclusion: 52 hemothoraces qualified as "minimal" and 47 as "moderate/large." Eight patients (15%) in the minimal group and 31 patients (66%) in the moderate/large group underwent intervention (P < .001). There was no difference in patient age, injury severity, ventilator requirement, or presence of pulmonary contusion. CONCLUSIONS: CAT in stable blunt-trauma patients can predict which patients with occult hemothorax are likely to undergo intervention. Patients with hemothorax > or = 1.5 cm on CAT were 4 times more likely to undergo drainage intervention compared with those having hemothorax < 1.5 cm.